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Suspected Liver Disease

General points

Asymptomatic LFT abnormalities can often be managed in primary care. Please see algorithm for asymptomatic abnormal LFTs. All referrals to hepatology require a complete non-invasive liver screen requested in primary care. There is an order set available on the ICE pathology requesting system.

Frequent causes are:

1.       Alcohol excess.

2.       Non-alcoholic fatty liver disease related to the metabolic syndrome.

3.       Viral hepatitis (acute & chronic).

4.       Prescribed and non-prescribed drugs - reconsider indications.

Statins are a common cause of abnormal LFTs but they rarely cause liver injury. It may be worth stopping them to check that LFTs normalise however they are safe to continue. Abnormal LFTs are not a contraindication to statin therapy.

STOP any implicated drug if: ALT > x 5 normal, elevated bilirubin AND any level of ALT/ALP elevation.

These issues should be addressed and LFTs repeated in 3 months. Referral to secondary care is not required at this stage, but may be considered if there are particular concerns e.g. Indices > 3x upper limit of normal. Alternatively contact hepatologist for advice.

If LFTs continue to be abnormal after 3-6 months:

Raised isolated bilirubin: Perform FBC - If Hb normal very likely Gilbert’s syndrome, reassure and give patient advice leaflet patient advice leaflet. 1.       If anaemic consider referral to haematology ?haemolysis

2.       Raised ALP: Confirm hepatic by raised GGT. If ALP >1.5x upper limit and GGT raised, request a complete NILD screen including US and refer to hepatology. If ALP is not >1.5x upper limit, adopt watch and wait approach and repeat in 6 weeks.

3.       Raised transaminases +/- ALP: Perform non-invasive liver disease screen.

AFP, Liver autoantibodies, Alpha 1 antitrypsin, LFT, AST with AST:ALT ratio, Coeliac screen, Caeruloplasmin (if<40 years), Lipid profile, Electrolytes, Ferritin, Glucose, Immunoglobulins, TSH, HBsAg and hepatitis C serology, CRP

ULTRASOUND

Manage accordingly:

1.       Alcohol excess and non-contributory NILD screen – consider referral to community alcohol team.

2.       Likely non-alcoholic fatty liver disease (non-drinker with metabolic syndrome and non-contributory NILD screen) – REFER to hepatology if: Diabetic AND BMI > 28 or

AST:ALT ratio > 0.8. Otherwise review annually and promote healthy lifestyle

3.       Possible drug side-effect – consider stopping – balance risks / benefits

4.       Hep B serology +ve – REFER to hepatology with HIV/HCV serology

 

 

5.       Hep C antibody positive: Perform Hep C viral load & request Genotype +

HIV /HBV serolology. If positive – REFER to hepatology. If negative – repeat 3m later and if still negative reassure patient infection has cleared, no need to refer.

6.       If ferritin > 500ug/L perform iron studies and if iron saturation > 65% then REFER to hepatology, otherwise consider other causes

7.       Positive anti-smooth muscle antibody or anti-mitochondrial antibody or raised IgG or IgM – REFER to hepatology

8.       Low alpha-1 antitrypsin level – REFER to hepatology

9.       No obvious cause – REFER to hepatology

 

 

 Algorithm for abnormal asymptomatic LFT investigation

Adapted from Fatty liver referral pathway, Phil Newsome QE Birmingham